Post Reply 
Help deciphering ins. benefit
Author Message
distantdreamer Offline

Members

Posts: 13
Joined: Mar 2015

Machine: AirSense 10 AutoSet for Her
Mask Type: Nasal pillows
Mask Make & Model: AirFit P10 for Her
Humidifier: HumidAir humidifier
CPAP Pressure: 6-12
CPAP Software: SleepyHead Other Software

Other Comments:

Sex: Female
Location:

Post: #1
Question Help deciphering ins. benefit
Hi all,

Anyone with insurance knowledge able to help me understand what this means? I found this in my benefits plan and I am unsure how to interpret it. I have a $2500 deductible, so I know I am going to pay almost full price for my equipment (if there is in fact a contracted rate available). But does this mean that I have to pay the rental fee until the stuff is paid off and then I keep it or give it back? I was just given an Rx for the AirSense 10 AutoSet for Her with the heated hose and a P10 mask. Not sure if my insurance will cover it based on the section I bolded below. Anyone have experience with BCBS PPO with high deductible



DURABLE MEDICAL EQUIPMENT (DME), MEDICAL SUPPLIES AND PROSTHETIC
APPLIANCES AND ORTHOTICS

Precertification: Not required.

Your Cost-Share: You pay applicable deductible and coinsurance. Your cost-share is waived for one
FDA-approved manual or electric breast pump and breast pump supplies per female member, per
calendar year. You also pay the balance bill for services provided by noncontracted providers.

H.1 Durable Medical Equipment (DME)

Benefit Description: To be eligible for coverage, DME must meet all of the following criteria:
• Be designed for repeated medical use in the home setting;
• Be specifically designed to improve or support the function of a body part;
• Cannot be primarily useful to a person in the absence of an illness or injury; and
• Intended to prevent further deterioration of the medical condition for which the equipment has
been prescribed.

Benefits are available for DME rental up to the purchase price of the item, as determined by
BCBSAZ, and for DME repair or replacement due to normal wear and tear caused by use of the item
in accordance with the manufacturer’s instructions or due to growth of a child. Benefits are limited to
the allowed amount for the DME item base model. BCBSAZ determines what is covered as the base
model. Deluxe or upgraded DME items may be eligible for coverage based upon BCBSAZ medical
necessity criteria.


Benefit-Specific Exclusions:
• Charges for continued rental of a DME item after the purchase price is reached (what does this mean...wont I own it after reaching the purchase price if rented? In a rent to own sense?)
• Repair costs that exceed the replacement cost of the DME item
• Repair or replacement of DME items lost or damaged due to neglect or use that is not in
accordance with the manufacturer’s instructions or specifications

Thanks in advance for any insight Smile
03-14-2015 12:43 AM
Find all posts by this user Post Reply Quote this message in a reply

Donate to Apnea Board
DeepBreathing Offline
Wiki Editor
Moderators

Posts: 2,291
Joined: Sep 2013

Machine: Resmed S9 VPAP Adapt
Mask Type: Full face mask
Mask Make & Model: F&P Simplus
Humidifier: Resmed H5i
CPAP Pressure: EPAP: 9 - 15 PS: 3 - 10
CPAP Software: ResScan SleepyHead

Other Comments:

Sex: Male
Location: Perth, Western Australia

Post: #2
RE: Help deciphering ins. benefit
I don't understand your system sufficiently to comment except to say that Resmed Autosense 10 Autosets are available from several of the suppliers on the list for under $900. You need to work out how much the rent to purchase scheme will cost and (if necessary)be prepared to walk away from it and buy your own machine.

DeepBreathing
Apnea Board Moderator
www.ApneaBoard.com


Bed

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
03-14-2015 03:09 AM
Find all posts by this user Post Reply Quote this message in a reply
on the virge Offline

Preferred Members

Posts: 53
Joined: Feb 2015

Machine: PRS 1 (560) Auto with A-Flex
Mask Type: Nasal pillows
Mask Make & Model: P10
Humidifier: Philips Respironics
CPAP Pressure: 7-11
CPAP Software: SleepyHead EncoreBasic Other Software

Other Comments:

Sex: Male
Location: Northern Virginia

Post: #3
RE: Help deciphering ins. benefit
I don't have BCBS but I remember earlier experience with Medicare and our parents, specifically, a hospital bed. I believe what that means is that you have two choices: 1) you can choose to continue renting in which case the vendor is responsible for repairs and maintenance or 2) you can choose to take ownership in which case you are responsible for repairs and maintenance.

The choice might have more significance for a piece of equipment that will only be used for a short period longer and is subject to needing maintenance. For CPAP, I believe everyone would choose to own the equipment at the end of the rental.
(This post was last modified: 03-14-2015 07:41 AM by on the virge.)
03-14-2015 07:38 AM
Find all posts by this user Post Reply Quote this message in a reply

Donate to Apnea Board
on the virge Offline

Preferred Members

Posts: 53
Joined: Feb 2015

Machine: PRS 1 (560) Auto with A-Flex
Mask Type: Nasal pillows
Mask Make & Model: P10
Humidifier: Philips Respironics
CPAP Pressure: 7-11
CPAP Software: SleepyHead EncoreBasic Other Software

Other Comments:

Sex: Male
Location: Northern Virginia

Post: #4
RE: Help deciphering ins. benefit
I don't have BCBS but I remember earlier experience with Medicare and our parents, specifically, a hospital bed. I believe what that means is that you have two choices: 1) you can choose to continue renting in which case the vendor is responsible for repairs and maintenance or 2) you can choose to take ownership in which case you are responsible for repairs and maintenance.
=============================
This used to be post 3 but I edited it to add what is now written in post 3. Used the back button in my browser to get back to forum. Browser displays can't find page, try later, I refresh page, same can't display, I use back button choosing to go back a few pages and discover that I have just reposted - not my intent. I try to delete post, I follow instructions that say check button to left click button to right. System goes to a page saying I don't have access search forum for how to edit my post, I search forum and it doesn't explain how to delete, I search "how to delete your post" search results say can find any results. this "do loop" is a pita. If there is some privilege that someone must earn before being able to delete their own post then the wiki search should identify it. Rant over.
(This post was last modified: 03-14-2015 08:01 AM by on the virge.)
03-14-2015 07:42 AM
Find all posts by this user Post Reply Quote this message in a reply
Mich Offline

Preferred Members-2

Posts: 119
Joined: Feb 2015

Machine: Resmed Airsense 10 Autoset For Her
Mask Type: Nasal mask
Mask Make & Model: Respironics Wisp/Resmed F10 on standby 4 allergy season
Humidifier: Airsense 10 humidifier
CPAP Pressure: 7-11
CPAP Software: SleepyHead

Other Comments: Mask recommendations: 1) Wisp 2) Eson (Avoid P10 and N10)

Sex: Female
Location: USA

Post: #5
RE: Help deciphering ins. benefit
You should call your insurance person, or the DMA accounting department to get exact figures. For me, the deals were rent/rent to own (15 months), or straight purchase based on rent to own 15 mo. I insisted on straight purchase which ended up being calculated a costing me $236 for the Resmed Airsense 10 Autoset for Her including mask of choice. I just did not want to have to write a check every month, and I own the machine!
03-14-2015 07:51 AM
Find all posts by this user Post Reply Quote this message in a reply

Donate to Apnea Board
Sleeprider Online
Wiki Editor
Advisory Members

Posts: 3,307
Joined: Dec 2014

Machine: Resmed Aircurve 10 Vauto
Mask Type: Nasal pillows
Mask Make & Model: Resmed Airfit P10
Humidifier: Resmed Climateline
CPAP Pressure: Auto Bilevel 18/9, PS 3
CPAP Software: ResScan SleepyHead EncoreBasic

Other Comments:

Sex: Male
Location: Where they make Respironics

Post: #6
RE: Help deciphering ins. benefit
Your policy apparently provides for rent to own for DME equipment like a CPAP machine. It covers the basic CPAP machine, which means the insurance billing code for CPAP, must cover all types of CPAP, including auto at the same allowable rate. We don't know what that allowable is. Typical DME sales itemize all CPAP components individually. Insurance is invoiced separately for CPAP machine, humidifier, Humidifier chamber, hose, filer, fine filter, hose and all of the mask parts, headgear, cushions, mask. That is the way the system works.

As a result, most DMEs are able to cover top of the line auto CPAPs under the allowable insurance cost. You cannot be billed more than the allowable cost, but that can be substantially more than online providers charge due to the way components are separately invoiced. Under your DME you will not own the machine until you demonstrate compliance and effectiveness.

With a $2500 deductible, my recommendation would be to buy your equipment out of pocket and submit a form for out of network reimbursement. That way most of your cost (60% depending on conditions) will apply to your deductible and copay. Your total out of pocket will be much less than if you stay in-network and work with a DME.

Basically you should expect that a new complete top of the line APAP and complete mask will cost $1000 using online sellers. I chose to buy lightly used units through local Craigslist sellers, and got a PR System 1 60 series Auto ($200) and a BiAPAP ($350). Each has less than 200 hours and I did not file for any insurance. I bought my mask and a heated hose kit through Supplier #2. I submitted an insurance form for that. So I bought everything, including a second machine for under $700. Hi deductibles suck, but if you don't expect to exceed them it is pointless to use higher priced in-network sources.

______________________________________________
Organize your SleepyHead Data
Post your SleepyHead Data from Imgur
Robysue's Beginner's Guide to Sleepyhead
03-14-2015 08:24 AM
Find all posts by this user Post Reply Quote this message in a reply
distantdreamer Offline

Members

Posts: 13
Joined: Mar 2015

Machine: AirSense 10 AutoSet for Her
Mask Type: Nasal pillows
Mask Make & Model: AirFit P10 for Her
Humidifier: HumidAir humidifier
CPAP Pressure: 6-12
CPAP Software: SleepyHead Other Software

Other Comments:

Sex: Female
Location:

Post: #7
RE: Help deciphering ins. benefit
(03-14-2015 07:51 AM)Mich Wrote:  You should call your insurance person, or the DMA accounting department to get exact figures. For me, the deals were rent/rent to own (15 months), or straight purchase based on rent to own 15 mo. I insisted on straight purchase which ended up being calculated a costing me $236 for the Resmed Airsense 10 Autoset for Her including mask of choice. I just did not want to have to write a check every month, and I own the machine!

I wish I could believe that I could get that good of a deal with my insurance. But considering when I called the sleep center for pricing of the study, they told me cash pay would be $750 so I could have some sort of idea what to expect cost wise. With my insurance it cost me $650 (of course with insurance the sleep center billed the insurance $3800!) So going with insurance saved me $100 from their cash price basically. I am fearful the equipment my end up the same kind of scenario.
03-14-2015 01:54 PM
Find all posts by this user Post Reply Quote this message in a reply

Donate to Apnea Board
distantdreamer Offline

Members

Posts: 13
Joined: Mar 2015

Machine: AirSense 10 AutoSet for Her
Mask Type: Nasal pillows
Mask Make & Model: AirFit P10 for Her
Humidifier: HumidAir humidifier
CPAP Pressure: 6-12
CPAP Software: SleepyHead Other Software

Other Comments:

Sex: Female
Location:

Post: #8
RE: Help deciphering ins. benefit
Well today I spent a very long time on the phone and got NO answers from my insurance company. I called a local DME, got all their insurance codes for billing so I would know what to get costs on from insurance. However the ins. co. could not give me what my allowable costs are because the diagnosis code came back as requiring medical review. I even said "so pretend it is approved" what are my allowable costs? Was then told they need the tax ID of the DME to verify if they are in network or out of network. Again, I asked "lets just pretend they are" and STILL no answers as she put me on hold to review something and I was subsequently disconnected. I hate the whole scam of insurance! Grrr.

I called the local DME back to see if they could give me any rough guess based on other claims w/ BCBS and she said that I will likely have to go the rental route as that is BCBS's preference and the their contracted rate for rental is $80/mo. What she couldn't tell me was my allowable coverage since BCBS has hundreds of different plans. Sad to say the DME has actually been the most helpful so far. I am going to fax them my info tomorrow so she can do the hokey pokey with BCBS and get me the costs. From there I suppose I will decide which route to go. Not too keen on the rental idea though.

Anywho, thanks to those of you who provided input. It was very helpful when I was trying to force info out of the ins. co. to have an idea of what to ask Smile
03-16-2015 08:56 PM
Find all posts by this user Post Reply Quote this message in a reply
Post Reply 


Possibly Related Threads...
Thread: Author Replies: Views: Last Post
Question Is there a benefit to increase my starting pressure? Rousseau21 10 1,501 09-13-2016 12:14 PM
Last Post: Maskup Sleepwell
  Deciphering pulse rate data from oximeter sean333 5 411 09-01-2016 02:41 PM
Last Post: trish6hundred
  ANY BENEFIT WHILE AWAKE srlevine1 7 783 06-14-2016 07:30 PM
Last Post: raisedfist
  How much humidifier benefit if not using ClimateLine? TwoSleepy 10 882 05-02-2016 08:30 PM
Last Post: archangle
  any benefit of narrowing pressure ranges ckingzzzs 7 804 11-05-2015 06:24 PM
Last Post: Ghost1958
  [News] OSA Patients Benefit from Auto-Titrated CPAP Before Surgery ApneaNews 1 1,599 10-01-2013 05:42 AM
Last Post: DocWils
  Deciphering Respironics Humidifier Installation Instructions Ermine 8 2,647 09-02-2013 07:26 PM
Last Post: Sleepster

Forum Jump:

Who's Online (Complete List)